As part of the Compliance Department Special Investigations Unit (SIU) team, the primary duty of the position is to assist the SIU Manager and the SIU FWA Analyst with State and Federal deliverables and perform reviews of claims flagged by the Steward Health Choice Fraud, Waste and Abuse (FWA) vendor (Vendor) and preparing suspected FWA cases for clinical and coding investigators for the purpose of improving payment accuracy and preventing FWA.
Conduct reviews of flagged claims and suspected FWA, identifying opportunities for improving payment accuracy and preventing FWA.
Review claims flagged by Vendor with GÇ£do not payGÇ¥ recommendations and suspected FWA cases in an accurate, efficient and timely manner.
Conduct outreach to physicians and office staff for medical records when needed to support review of flagged claims;
Prepare referrals for preliminary investigations, including but not limited to: Requesting medical records, creating forms, reports and updating logs.
Assist SIU FWA Analyst with preliminary investigations
Assists in maintaining compliance with timely completion and reporting of State and Federal deliverables
Professional Competencies (knowledge, skills, and abilities):
GÇó Microsoft Windows applications.
GÇó Knowledge of Medicaid and Medicare programs.
GÇó Strong customer service skills and techniques.
GÇó Strong presentation, oral and written communication skills.
GÇó Ability to effectively interact with staff, customers and management at all levels.
GÇó At least two (2) years of health plan processes, compliance and FWA preferred